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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1578593

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Case Details

VAERS ID: 1578593 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-06-15
Onset:2021-06-23
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-08-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0191 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Death, Vaccination complication
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations: Pertussis reaction as newborn
Other Medications: Gabapentin Clonazepam Baclofen Cimetidine
Current Illness: N/A
Preexisting Conditions: Depression and anxiety
Allergies: Penicillin
Diagnostic Lab Data: Forensic Pathologist after full autopsy determined patient was a healthy adult with no heart disease, no liver disease, and no pnemomia. Coroner determined after toxicology report that covid 19 vaccine was the only contributing factor. Everything else was ruled out.
CDC Split Type:

Write-up: Died June 25th after cardiac arrest on June 23rd, 8 days after his vaccine.


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